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TO THE EDITOR:Re: Routine Use of Intraoperative Neuromonitoring During ACDFs for the Treatment of Spondylotic Myelopathy and Radiculopathy Is Questionable A Review of 15,395 CasesWe thank the authors for their commentary on our article.1 We do agree that our study did not specifically assess the risk of neurological injury within each diagnostic criteria [such as myelopathy, radiculopathy, Ossification of Posterior Longitudinal Ligament (OPLL)], among others. However, our methodology is in line with several other studies that have assessed the impact of neuromonitoring on postoperative neurological injury following anterior cervical spine surgery in patients with a variety of cervical spine pathologies. For example, in a study by Lee et al3 on 1445 patients with a variety of cervical spine pathologies (including myelopathy, radiculopathy, tumor, OPLL, infection, and trauma) that had anterior cervical spine surgery, the risk of a new neurological injury was reported to be low (0.1%). Having a diagnosis of myelopathy and trauma compared to radiculopathy increased the risk of having a major intraoperative neuromonitoring alert, though these alerts were considered “subclinical” because they did not necessarily translate into a new postoperative neurological deficit. It is important to note that the two patients that developed a new postoperative neurological deficit in the study by Lee et al3 had corpectomies instead of anterior cervical discectomy and fusions (ACDFs) alone. Anterior cervical spine surgeries involving a corpectomy are considered to be high risk compared to ACDFs alone. As such, patients who underwent a corpectomy were specifically excluded from our study.Our group recently published a systematic review and meta-analysis on the use of intraoperative neuromonitoring in anterior cervical spine surgery.2 In that study, we analyzed 10 studies (which does not include the current study) totaling 26,357 patients. The weighted risk of neurological injury was 0.2% for ACDFs compared to 1.02% for corpectomies. For ACDFs, there was no difference in the risk of neurological injury with or without neuromonitoring, which is in line with the results in the current study. As such, we believe that the nature and invasiveness of a procedure to be performed, that is, corpectomy, deformity correction, among others, are a better predictor of neurological injury risk and should guide the decision on whether or not intraoperative neuromonitoring should be used in anterior cervical spine surgery.